Alexander Technique + Systemic Causation
First let me say that this website is an exceptional resource. There is an incredible amount of information out there on the internet about CTS -- most of it contradictory and confusing.
I'm planning to share my story in another post when I have more time to write it up (amateur jazz guitar/full time office worker with light CTS symptoms for 3 months now), but I wanted to ask some questions since I hadn't seen them receive conversation yet.
1. What are the relationships between the carpal tunnel and the rest of the body, particularly the neck, spine, and back? Can CTS be an outcome of systemic muscular imbalances? Having studied systems thinking I am increasingly amazed at how segmented and isolated treatment is here in the US (I'm based in Philadelphia). My wrists have been looked at in isolation from the rest of my body, and I am convinced that if I do not address the health of my body as a whole system (including mental and physical components) then CTS is bound to return in the long term. Which leads me to my second question:
2. Have there been any studies on the use of the Alexander Technique in addressing CTS or other repetitive strain injuries? The Alexander Technique is essentially a process for learning how to avoid unnecessary muscular and mental tension during everyday activities. A brief google search will reveal some anecdotal stories about people who have conquered repetitive strain injuries using the technique, however there seems to be nothing well documented.
I have taken one lesson with a teacher, so it's too early to tell whether or not it is helping my wrists. (By the way, if you're reading about the technique and trying to apply it, don't bother. You really do need a teacher to get their hands on your body and educate you about what you're doing.) The reason I'm pursuing it is because I've heard several musicians I know and deeply respect (Julian Bream, Julian Lage) pursued the technique after injury and said it was very helpful. The teacher I'm learning it from is also a musician and claims the Alexander Technique was the only thing the resolved his arm and shoulder pain after trying a variety of treatments (yoga, massages, etc -- I don't think he had CTS though!).
My understanding is that the alexander technique is a systemic approach to optimizing the use of the musculo-skeletal system, reducing overall stress and maximizing efficiency of movements. If this is indeed a viable approach to addressing repetitive strain injuries (which I believe it is based on multiple anecdotal stories from people I trust--of course not very useful for medicine), then it makes sense to me that yoga is also a potential alternative treatment; yoga can address muscle relationships and remove systemic imbalances if done appropriately.
So, my theory is that CTS is an outcome of some systemic imbalance. I would appreciate commentary on whether or not any of this makes sense and if there is any research into these areas, if it is simply not the case, etc.
In my case, there was clearly a single event that triggered the symptoms (I played a three hour gig and my wrists haven't been the same since). Appropriate technique (use of wrists, hands, position of neck and back, minimal tension) should address performances issues, which is where the Alexander Technique comes in for me. I am pursuing more lessons and will update the thread with new developments.
I have a million questions about CTS that I'm holding off on asking, too.
Mark
Thank you for your detailed response -- very interesting comments. I too am surprised there has not been a study of yoga for CTS. Part of the problem for me in pursuing yoga has been: what type, what poses? There's plenty of different forms to study, and I would rather have input from a doctor with insight into what you should and shouldn't be doing with the wrists than a yoga practitioner who doesn't understand CTS. Websites seem to offer various wrist stretches and poses -- but some of that stuff seems like it might aggravate the wrist in the first place.
With regards to your second answer: that is a fair point. I do not mean to blame the doctors, but the healthcare system. Speaking from my experience, there seems to be increased pressure to process services as quickly as possible. Doesn't leave too much time for a holistic survey of patient health.
In my instance I believe that some of these systemic factors (looking at external environment) are how I use my hands and wrists on both the instrument and keyboard. The alexander technique has so far done a good job of making me aware of excessive strain. Identifying this and reducing tension has produced a considerable improvement in the amount of pain I feel after a day of computer use. Like I said, I'm only one lesson in, so hopefully I can report better news in the future.
A Google search for "carpal tunnel syndrome" didn't reveal this website, even searching up through page eleven (I used ctrl+f on each page so I couldn't have missed it). However, "Carpal tunnel forum" lists you as the first one, so you have that going for you. If you have some spare dollars and are looking to cast your net wider it might be worth some spending some money on search engine optimization, google adwords, or some facebook ads. A shame that this doesn't appear in general searches for carpal tunnel.
In the UK we are in the first page of "carpal tunnel syndrome" or just "carpal tunnel", and we are also the first two hits for "failed carpal tunnel surgery" - which says something about which patients are looking for infomration on the web I think. I'm not doing any more SEO for now I'm not a business needing to attract traffic :-) I can find the one Yoga paper for you if you can's access it online anyway. JB
Understood -- if someone is frustrated and curious enough they'll surely find you anyway.
Found the Yoga paper:
Garfinkel, M S. Singhal, A. Katz, W A. David, A A. Reshtar, R (1998) “Yoga based intervention for carpal tunnel syndrome: a randomised trial” JAMA 280:1601-1603
Posting here for future reference:
"Subjects were randomized into 2 groups by having them select sealed envelopes containing a group assignment. Subjects in the control group were offered a standard wrist splint with a metal insert (if not already in use) to supplement their current treatment. Subjects in the yoga-based intervention group received a program focused on upper body postures: improving flexibility; correcting alignment of hands, wrists, arms, and shoulders; stretching; and increasing awareness of optimal joint position during use. We used the Iyengar approach to hatha yoga, which emphasizes proper structural alignment of the body and is based on the teachings of yoga master B. K. S. Iyengar.3,5 The method of study is orderly and progressive, and postures are adjusted to meet the physical conditions of the subjects. With education in the postures (asanas), habitual poor posture can improve. As musculoskeletal alignment improves, the ability to perform the asanas also should improve. Potential benefits of this method include improvements in strength, coordination, and flexibility and an increased sense of well-being.
The sequence of postures used in this study was designed to focus on the upper body for subjects with CTS. The exercises were performed while the subject was sitting and standing and were designed to take each joint in the upper body through its full range of motion with strengthening, stretching, and balancing each part."
Exciting stuff -- I'm looking into teachers here in Philadelphia. Bummer that my insurance doesn't cover Yoga therapy...!
The full paper does include a list/descriptions of the 12 postures used. I can email you a copy if you need it for personal reference as a patient but it is copyright so I can't put it on the public website. JB
No problem Dr, I found the full paper but didn't want to post here for those reasons. Is that excerpt above okay?
Yes the abstract is fine - that's public domain. There's also a summary of the paper in the 'alternatives' page here already. I don't know why no-one has ever followed it up. JB
1) Health information on the net - yes it is a bit of a nightmare for patients. Generally it is good to start with general health information sites run by national health services - the NIH in the USA, NHS choices in the UK etc as these have usually been written by people who know what they are talking about. When such sites provide a link to a specialist information site these are also generally fairly reliable - though I have failed to get the US authorities to link to here - they have a blanket policy of not linking to non US sites!. Secondly the HonCode certificate is a good marker. Thirdly any site which is run by the manufacturer of a device/treatment for which you have to pay is immediately suspect and should probably be ignored - the dictum "follow the money" is a good one. I would be curious to know where this site is currently appearing in a google search for "carpal tunnel syndrome" in the USA - I get a lot of US visitors but google's answers vary depending on where you are so I can't tell easily from here.
2) The question of how 'connected' CTS is with the state of health of the rest of the body is a complex one I think. We conventional medical practitioners are often accused by the 'alternative' lobby of not considering the whole person but this is of course nonsense. Doctors are well aware of both the fact that individual pathological processes take place in the context of an entire human organism with individual characteristics which will influence the disease process being considered, and also the fact that the consequences of disease for any given individual will depend on a host of social, environmental, psychological and economic circumstances. Sadly most conventional doctor-patient interactions, at least here in the UK, do not allow time to fully explore such issues so although the doctor wil be thinking about the whole patient, the impression likely to be gained form the other side of the consultation will often be that he/she is entirely focussed on one bit of anatomy or physiology. The degree to which the holistic context is important will vary from one condition to another.
In CTS there are two levels to this. Firstly the median nerve does not just pass through the carpal tunnel. It runs all the way from the neck to the fingers (albeit with some complicated wiring at the top end in the form of the brachial plexus) and the topic of 'double crush syndrome' has received lots of interest. Secondly we can debate the extent to which the health of the median nerve at the wrist is influenced by your more generalised state of health. If, for example, you have widespread vascular disease, diabetes, or are taking potentially neurotoxic drugs or 'hormonal' treatments such as exemestane these will have an influence in the carpal tunnel and it is not imppossible that this sort of thing extends as far as general levels of cardiovascular and muscular fitness which have effects on all tissues. The idea of 'muscular imbalance' however is a vague one with little scientific validity - especially when applied to a patient who is apparently walking about, playing a musical intrument and carrying out ordinary activities in a fairly normal fashion. It's a bit different when there is an obvious problem such as torticollis (wry neck) which can fairly be described as an imbalance of muscular tone. My guess is that the relative importance of 'systemic' and 'local' factors in CTS in the average case is about 30-50% systemic (though the vast majority of that is genetic risk) and 50-70% local at the wrist.
3) Alexander technique - I can find no references specifically to this in CTS in my reference database and nothing on the web which is not either personal anecdote or essentially trying to sell classes so I think one has to conclude that there is probably no satisfactory scientific evidence that it has a specific effect to treat CTS. In a similar vein it is curious that no-one ever seems to have followed up the single preliminary trial of Yoga for CTS. There is probably room for someone to carry out a trial - one could compare for example the effect of an alexander teacher with a conventional physiotherapist - I think you could set this up so that the patients were not aware of which discipline they were being sent to. As with all treatments I think the onus is on the practitioners proposing them to provide definite proof of efficacy It's not my job to investigate every off the wall idea for something which might influence CTS - if you look at the alternatives page you will see that there is a very large range of these and I have to focus my attention on the most promising. JB